HospitalInspections.org

Based on medical record review, document review and interview, the governing body does not ensure medical staff are accountable for the care provided to patients, specifically that verbal orders are used infrequently, are authenticated promptly, are dated/timed and have implemented policies consistent with State and Federal regulations.

Findings Included:

Interview on 10/21/11 at 1045 with Staff #2 and Staff #3 revealed orders come from other facilities. Sometimes Staff #1 will see a patient at Olean and send orders with them. We write our orders from that information. If there is a discrepancy in the orders we call Staff #1. We have his office number, home number and cell phone number. Sometimes we call the pharmacy.

Interview on 10/21/11 at 1100 with Staff #3 revealed Staff #1 is the medical director and assumes care for all rehabilitation patients. Staff #1 is here at noon Monday through Thursday and at 1500 on Fridays. There is an on-call physician on weekends from the Urgent Care Center and a nurse practitioner who also covers patients. They try to admit patients in the morning so that all disciplines are available to perform their assessments.

Review of policy "Standard Physician Orders" last reviewed 6/11 revealed physician's medical care/rehab services standard orders will be obtained from the attending physician at the time of admission. The form will be signed and dated by the physician. Telephone or verbal orders for medical care/rehab patients must be countersigned by the physician within 48 hours of receiving the orders.

Review of policy "Medication: Verbal and Written Physician Orders" last reviewed 2/09 revealed verbal orders of medication shall be received and recorded by the pharmacist or licensed nurse. All verbal orders must be read back to the physician/PA and documented. The prescriber shall co-sign the order within 24 hours.

There is a discrepancy between these two policies related to the timeframe in which orders must be signed off by the prescribing practitioner.

Review of medical records for Patient #1-3 revealed the following:
- Patient #1: The preprinted medical rehabilitation standard orders dated 10/4/11 revealed telephone order not timed and authenticated by the physician.
- Patient #2: The preprinted medical rehabilitation standard orders and physician admission orders dated 10/4/11 at 1500 were not authenticated by the physician.
- Patient #3: The preprinted palliative care standing telephone orders dated 9/24/11 at 1425 was not authenticated by the physician.

Review of the Quality Assurance Medical Records Deficiency Report dated 10/21/11 at 1228 revealed that Staff #1 has 51 physician orders with dates ranging from 9/9/11 to 10/14/11 which were not authenticated. Other unsigned documents by Staff #1 include transfer forms, dictated history & physicals, dictated progress notes, dictated discharge summaries, and dictated death records.